| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,844 |
2,834 |
$221K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,471 |
2,469 |
$164K |
| D1120 |
Prophylaxis - child |
3,214 |
3,206 |
$148K |
| D1110 |
Prophylaxis - adult |
1,642 |
1,635 |
$147K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,852 |
1,060 |
$124K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
253 |
211 |
$120K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
684 |
324 |
$81K |
| D0230 |
Intraoral - periapical each additional radiographic image |
16,774 |
4,200 |
$80K |
| D0210 |
Intraoral - complete series of radiographic images |
1,577 |
1,575 |
$76K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,662 |
4,647 |
$65K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,017 |
596 |
$55K |
| D0274 |
Bitewings - four radiographic images |
2,544 |
2,532 |
$55K |
| D1351 |
Sealant - per tooth |
1,350 |
440 |
$50K |
| D4341 |
|
515 |
193 |
$36K |
| D4910 |
|
434 |
432 |
$33K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
384 |
281 |
$31K |
| D9430 |
|
874 |
863 |
$28K |
| D0350 |
|
2,030 |
942 |
$22K |
| D1310 |
|
368 |
367 |
$16K |
| D0272 |
Bitewings - two radiographic images |
599 |
598 |
$7K |
| D9993 |
|
96 |
96 |
$6K |
| D0330 |
Panoramic radiographic image |
203 |
203 |
$6K |
| D1206 |
Topical application of fluoride varnish |
188 |
187 |
$6K |
| D2330 |
|
16 |
12 |
$1K |
| D0270 |
|
231 |
228 |
$1K |
| D0602 |
|
56 |
56 |
$780.00 |
| D0603 |
|
29 |
29 |
$405.00 |